Last week saw the publication of an important randomized control trial of cognitive processing therapy (CPT) for Congolese survivors of sexual assault in the New England Journal of Medicine (NEJM — and thanks, NEJM, for making the article available in full online). The fruit of intensive work by Judy Bass of Johns Hopkins, Jeannie Annan of the International Rescue Committee, Debra Kaysen of the University of Washington, and a host of others, this publication sets a new standard in the field of post-conflict mental health research and is welcome news for those affected by rape and other forms of sexual assault in low and middle-income (or, “LMIC”) war-affected settings.

The study involved almost 500 female survivors of rape in the eastern provinces of the Democratic Republic of Congo (DRC), an area of the world infamous for the absence of state control and an ongoing epidemic of sexual violence. Half were randomly assigned to a group-based version of CPT led by trained local counselors, half to generalized, patient-directed individual support and case management. Those attending CPT improved far more than those in the control group (although the latter also improved somewhat).

CPT has been shown to be effective for sexual assault survivors in several Northern, high-income countries, so that it was effective in the DRC may seem unsurprising. However, debates have raged in the past decade or so about the efficacy and effectiveness of doing psychotherapy in post-conflict settings that are not technically “post”-conflict and in populations with low-levels of education.

Prior research has suggested that short-term therapies may not be effective for populations exposed to ongoing trauma or multiple severe traumas. In our study, all villages reported at least one major security incident during the trial, including attacks, displacement due to fighting, and robbery by armed groups. In addition, there was concern that providing therapy to illiterate persons would be challenging. Our findings suggest that despite illiteracy and ongoing conflict, this evidence-based treatment can be appropriately implemented and effective.

This study shows that, with sufficient technical support, psychotherapy targeting trauma-related emotional problems can be delivered effectively in violence-affected LMICs as part of comprehensive psychosocial programs.

If you have paid attention to any news from the Northeast U.S. in last couple weeks, you know that here in New York and across the river in New Jersey many people are hurting in the wake of the “superstorm” Sandy. According to the New York Times, there are an estimated 10,000-40,000 internally displaced persons (IDPs) in New York City alone. In response to the massive loss and devastation along the waterfront, there have been many heartwarming displays of care by neighbors, friends, and even complete strangers. And in contrast to the response to Hurricane Katrina in New Orleans, local government and even the Feds seem to have their act together in providing supplies and now housing to those displaced.

IDP issues may, however, become a long-term issue. The sudden loss of material goods and social connections that people have based on where and how they live can have long-term consequences for social capital, employment opportunities, and even just knowing how to complete everyday tasks (e.g., where to get healthy food for your kids). The outpouring of support needs to be transformed into long-term engagement with IDPs, along the lines of the better psychosocial programs undertaken in more severe IDP crises (e.g., in Medellín, Colombia).

In the meantime, there has been a little attention to mental health. The best I have seen so far has been a post by “The 2×2 Project,” a blog written by Dr. Lloyd Sederer out of Columbia University’s Mailman School of Public Health. (A thank you to my wife, who forwarded me the link.) Here’s the intro, which sums up and corrects the myths that are often hears in immediate post-disaster environments:

In the aftermath of Hurricane Sandy, opinions—some reliable, some misleading— about the storm’s potential mental health impact have proliferated. When media channels act responsibly they engage experienced experts as spokespeople; when that does not happen, wrong information adds to the public’s anxiety and can foster inappropriate clinical interventions and waste resources.

In the latter category, perhaps the greatest myths I have heard are:

Post-traumatic stress disorder (PTSD) can appear in the immediate wake of a disaster.

Watching television can cause PTSD.

The highly common psychic distress in the wake of a disaster is a mental illness.

Here are some facts:

Psychic distress after a disaster, which can be highly prevalent and last up to a month, generally is a normal reaction to an abnormal situation.

Read the rest of the post (and check out other informative posts) here.

The annual meeting of the International Society for Traumatic Stress Studies (ISTSS), this year held in Los Angeles, wrapped up this weekend. This year’s theme, Beyond Boundaries: Innovations to Expand Services and Tailor Traumatic Stress Treatments, was in large part a response to a lack of global and cross-cultural perspectives at most ISTSS meetings. This year the planning was directed by two global mental health researchers, Debra Kaysen (University of Washington’s Global Mental Health program)and Wieste Tol (Johns Hopkins). Thanks to Debra and Wietse and their deputies (disclosure: the latter crowd includes yours truly), global perspectives were given the main stage. This was most obvious in two of the keynote addresses, one by global mental health luminary Vikram Patel (Kings College London School of Hygiene and Tropical Medicine and founder of Sangath) and longtime transcultural psychosocialist Joop de Jong (the founder of Transcultural Psychosocial Organization (TPO), professor at VU Amsterdam (which is the link), the University of Amsterdam, Boston University, Rhodes University in South Africa). (A request to academics from the blogosphere: If you’re going to hold appointments at multiple institutions, please host your own website — finding which link to post ain’t easy.)

In addition to the international perspectives, it was good to hear the issue of capacity building addressed head on. This was addressed in the keynotes, but it also had it’s own symposium. Theresa Betancourt (Harvard) chaired “Capacity Building in Low-Resource Settings,” and she laid out the issue as movement from “relief to resource,” which sums it up nicely. Speakers included Vikram Patel, Mary Fabri (formerly of Heartland Alliance in Chicago), and Joop de Jong. One of the key problems in global trauma practice is that mental health professionals from high income countries fly in to low and middle income countries (LMICs), do their thing for a few weeks or a few months, then fly out — leaving nothing in terms of increased ability to deal with the long-term issues related to disasters, let alone in terms of preparation for subsequent ones. Capacity Building in Low-Resource Settings was a discussion of how to guard against this all too frequent phenomenon.

Vikram Patel noted that a key to “scaling up” access to empirically supported treatments was identifying “primary tools of mental health… skilled human beings.” Patel is well-known for advocating “task-shifting” to “nonspecialists” — in the US we would call them paraprofessionals. His preferred term is “counselors,” as it is a now globally familiar term because of the widespread use of counselors for medication adherence issues in HIV/AIDS work and breastfeeding (the two global public health predecessors Patel looks to as models for global mental health). Important “soft skills” (i.e., non-content specific capabilities) that are basic to counseling include: engaging patients, assessing their mental health, suicide assessment, and knowing when to refer to more skilled professionals. The next stage of training involves advanced competencies that are disorder-specific, treatment-specific, and health context specific. Acquiring these competencies involves brief (a few days) classroom training and then moving trainees on to supervised field work (a few months). One of the major stumbling blocks to sustainability of any counseling program is the lack of consistent supervision. Patel has moved to a model that includes peer supervision with web-based (e.g., Skype) supervision done remotely. He noted that as very often counsellors do much more therapy than senior supervisors, peer supervision is often better than supervision by senior intervention researchers.

These themes were taken up by Mary Fabri and Theresa Betancourt in explications of their clinical interventions efforts with women in Rwanda and former child soldiers in Sierra Leone, respectively. A common problem was remote supervision. Certainly Skype and other web-based communication helps connect experienced clinicians, but connection speeds being what they are — or rather, what they are not — in many lower income countries, these are often simply not feasible. Fabri makes frequent trips, and Betancourt gets by with large telephone bills for weekly supervision.

Only just touched upon was how these programs, sustained largely with external funding, can be integrated into a countries’ national health strategies. One particularly sticky issue related to certification. Joop de Jong noted that “professionalizing” lay workers has historically been accompanied by nongovernmental organizations’ (NGOs) ignorance to local politics. The inability to engage established local authorities makes them (understandably) angry, which then leads to barriers to certifying those who have been working with NGOs following post-conflict periods (and may extend to them being unable to access educational resources as well). It is during these “post-post-conflict” periods where the sustainability of programs is proven.

Left untouched was the issue of building research capacity. But research capacity building was not left undiscussed at the conference. Later in the evening I had the good fortune to be at dinner with Marc Jordans, the Research Director at HealthNet TPO (also at Kings College London School of Hygiene and Tropical Medicine), who has made research capacity a priority. He explained the process as excruciatingly slow, as the challenges are largely educational. Here’s where the distinction between lower income countries and middle income countries is critical. Middle income countries (MICs — e.g., India, Peru) tend to have university systems, and therefore a pool of educated researchers in a field that uses research methods applicable to mental health research (.e.g, sociology, anthropology, public health); lower income countries (LICs — Sierra Leone, Nepal), however, often have one or two universities, and a very small pool of people with the base level research understanding to build upon. In essence, groups like HealthNet TPO are engaged in educational development, which, like all development work, is a multi-decade proposition. Jordans added, however, that the payoff for homegrown LIC researchers with a PhD is great, given that they are one of a few in their countries with the expertise and legitimacy to advise governmental and international organizations working in their regions.

Last week saw the annual meeting of the Society for the Study of Psychiatry and Culture (SSPC) in New York City. SSPC’s mission includes “furthering research, clinical care and education in cultural aspects of mental health and illness,” and although somewhat small includes some of the most prominent thinkers in the world of psychiatry and culture. These are the people who go beyond simplistic cultural diatheses (e.g., individualism versus collectivism), incorporating multidimensional frameworks that include political factors as well as ethnicity and race.

Among the livelier presentations was a report by Roberto Lewis-Fernandez, Neil Aggarwal (both at Columbia), Laurence Kirmayer (McGill), and Renato Alarcón (Mayo Clinic and Universidad Peruana Cayetano Heredia) on much needed updates to the Cultural Formulation guidelines in the upcoming DSM-5. The DSM — Diagnostic and Statistical Manual — is the American Psychiatric Association’s official guidebook to human psychopathology, and the current version, DSM-IV-TR, is largely accepted as the last word on mental health problems in psychiatry, psychology, social work, and related disciplines. Cultural Formulation guidelines are suggestions for how clinicians should conceptualize the role of culture in patients’ mental health problems. The guidelines appeared first in the pages of the DSM-IV (1994), but, along with a short and messy list of “Culture-Bound Syndromes,” were placed in the back of the book where few practitioners would ever find them.

This time around there is a widespread effort to place the Cultural Formulation front and center in the DSM-5. Drs. Lewis-Fernandez and Aggarwal reported on a tool designed to make cultural formulation quicker and easier, the Cultural Formulation Interview, or CFI. The CFI is meant to be administered during patients’ initial assessment, and consists of 14 questions. Many of these questions are just good clinical practice. For instance, the first question is, “What problems or concerns bring you to the clinic?” Although there are hints at what might be considered culture by question three (“People often understand their problems in their own way, which may be similar or different from how doctors explain the problem. How would you describe your problem to someone else?”), it’s not until the seventh question that culture is explicitly mentioned: “Is there anything about your background, for example your culture, race, ethnicity, religion or geographical origin that is causing problems for you in your current life situation?”

The point of framing the questions this way is to not make a big deal of culture while at the same time getting a good person-centered assessment that considers culture as important to how patients view their problems. This is meant to avoid the stereotyping that considering culture often leads to in situations in which clinician and patient differ on some cultural dimension. The CFI seems to provide space for individuals to define their problems as they see fit — i.e., to make explicit their own explanatory models — and then relate this to how others within their social networks (including family members and those that don’t share their culture) may see their problems.

My favorite exchange came after one audience member looked over the CFI and asked, “For whom would these questions not be relevant?”

Dr. Lewis-Fernandez replied: “Yes, exactly.”

The CFI is currently undergoing field trials. Read more about the proposed DSM-5 Cultural Formulation and the CFI, and express your opinion as to whether it should be emphasized (or not, I suppose), by following this link to the DSM-5 commentary website. Common sense needs advocates.

On a related note: If you haven’t read it yet, Allen Frances’ Op-Ed in Saturday’s New York Times, provocatively titled Diagnosing the DSM, is worth it. In it Dr. Frances, one of the architects of the DSM-IV, argues strongly that the DSM-5 development process should be untethered from professional psychiatry in order to build a better product. A teaser:

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.

The September 2011 issue of Transcultural Psychiatry is out, and it includes an article by myself and some colleagues based on some work we did with Darfur refugees a few years ago. Publication lag times as they are (a colleague this morning compared them to the aging of fine wines), by the time an article is finally comes out in print the author’s ideas about what he/she sees as the “take-home” message may have shifted slightly. So here’s my chance to provide the 2011 take-home to a study written in 2009.

We took an emic-etic integrated approach, identifying local constructs and then measuring both Western and local distress constructs within the same population in order to compare associations between two sets of symptoms of theoretically related concepts.

This means we (1) talked to a lot of refugees to hear how they defined their problems (including symptoms of psychological distress) and then followed-up with traditional healers to hear how they categorized these symptoms into larger psychological problems (“idioms of distress” for you budding transcultural psychiatrists out there); and (2) conducted a survey that included these problems and Western concepts (PTSD, depression) to measure how the Darfur problems and Western concepts were differentially associated with trauma experiences, loss, and impairment in daily living. The two Darfur problem sets were labeled hozun — “deep sadness” — and majnun — “madness.”

I’ll let you read the article to get the details, but suffice it to say that these sets of disorders — hozun and majnun on the one hand and PTSD and depression on the other — shared many symptoms in common. Related to this, they were associated with traumatic events and functional impairment at comparable levels — in other words, one could “predict” functional impairment using hozun and PTSD and get similar effect sizes (with slight favor for the locally-defined problems).

One might think that if a measure of PTSD is as good as measure developed for a local distress idiom in predicting a third variable you are interested in, then there is really no reason to develop the local measure. In the article we emphasized that the response to this argument had to do with respecting local populations and avoiding psychiatric colonialism. Now although I agree with those ideals, I would emphasize another point we made (but did not emphasize): Just because many of the symptoms of two different disorders from the Western psychiatric canon (here PTSD and depression) overlap with two different disorders from a different medical tradition (here hozun and majnun), it is how the symptoms are arranged in their respective traditions that define the disorders. From the article:

although they accounted for similar variance in Study 2 as a set of items, these symptoms were categorized by traditional healers into sets that were different that the sets of symptoms in PTSD and depression. This, then, suggests that it would be incorrect to argue that PTSD and depression are culturally valid constructs in settings in which respondents report variance on PTSD and depression simply because of that variance.

In other words, just because non-Western participants in a study answer that they have problems (or do not have problems) that fit into Western DSM-IV ideas of psychiatric disorder does not mean that Western DSM-IV ideas of psychiatric disorders are valid definitions of their problems. Figuring out what are valid definitions for their problems is not, at its most basic, a statistical task, but rather a theoretical one. You have to talk to the people who know the theory, not just the people who have the problems.

Dogs bring home war’s stress, too

Years of war and frequent deployments have affected military working dogs just as they have humans, and Dr. Walter Burghardt is trying to do something about it.

Dr. Burghardt explains:

“The dogs that go overseas … we’re starting to see some distress-related issues,” he said. “It results in difficulty doing work. They’re distracted by loud noises. We’re not saying it’s the same as in people, but there are common things.”

That includes hypervigilance or showing interest in escaping or avoiding places in which they used to be comfortable. For example, a dog that used to work at a security checkpoint or gate may try to pull away on his leash when he sees he’s being led to that checkpoint or gate, Burghardt said.

Some of the dogs also become very clingy or more irritable or aggressive, the doctor said.

“Canine PTSD” is either the most extreme example of what Richard McNally calls PTSD’s “bracket creep” or some perhaps nonintentional Pavloivan insight into the nature of stress response. Or perhaps both. If we take the “symptoms” reported in the article as accurate, and I have no reason to doubt the staff writers at the Army Times, then yes, dogs get stressed and want to avoid the sources of their stressors — classical conditioning, a la Ivan Pavlov (1849-1936; Pavlov even demonstrated conditioning using dogs, until they drowned in their cages when the River Neva flooded the basement of his laboratory). But canine posttraumatic stress disorder?

In case you were concerned that the Army veterinarians were not being careful about differential diagnosis, or perhaps even that some dogs might be faking in order to cash in on the generous disability benefits for veterans with PTSD:

[Dr. Burghardt] cautioned, “canine [post-traumatic stress disorder] is only diagnosed if the dog has combat exposure or repeated, prolonged deployments.”

The article continues with a description of the treatment given the dogs to get them right back “in the service”… which is, of course, the goal of treating human PTSD in the military as well.

McGill University’s Summer Program in Social and Cultural Psychiatry is not just about the differences between Swedes and Irish. As part of the summer program’s keynote course, Cultural Psychiatry, McGill luminary Laurence Kirmayer includes a number of film clips in the syllabus to give students a chance to observe some of the phenomena that gets diagnosed by psychiatrists using Western psychiatric categories, but may perhaps make more sense by examining the patient’s cultural and historical context.

One of the most striking films shown (so far) comes from Robert Lemelson’s psychiatric anthropology series, Afflictions: Culture and Mental Illness in Indonesia. In “Shadows and Illuminations,” a man presents with visual and auditory hallucinations of Balinese spirits, disorganized behavior and inappropriate dress. His family and neighbors regard him as odd, so it’s not the case that he is just odd to our foreign eyes. Our psychiatric practice tells us to look for schizophrenia. He reports the symptoms began with the death of his daughter, and we think perhaps it is a posttraumatic stress reaction of some sort. He is examined by two traditional healers and a psychiatrist, all of which have their own treatments, but none of which seem to help. Accommodations are made for the man’s behavior in his own home, and he seems to get a little better. Improvement had nothing to do with our diagnosis, or lack thereof.

Each story in the series situates behavior and concepts of illness within the families and societies in which they occur. Not satisfied with biological explanations of these patients’ problems, Lemelson’s films remind us that psychiatric practices have non-psychiatric implications, specifically around family relations, historical meaning-making, and even implications related to the freedom of the individuals with mental health problems.